Antibiotics (Role and Abuse)

MM50110 Combined Lectures

Oct 2016
Leslie CHAN
 Common mistakes?
Patient has leptospirosis, give IV ceftriaxone
Patient has diarrhoea, give PO doxycycline
Patient has dengue, give IV antibiotics
Patient has flu, give oral antibiotics
Patient has MRSA, give oral vancomycin
Septic patient initially covered with iv
meropenem, blood cultures showed strep.
Pneumoniae sensitive to ampicillin; continue
meropenem because patient still not fully stable
 Continuous infusion of iv
piperacillin/tazobactam is better than (qid)
Single dose of gentamycin daily is as effective
as divided dose of gentamycin (tds)
Antibiotics have no side effects
For penicillin-sensitive Staph aureus,
vancomycin is equally as effective as
penicillin/ cloxacillin.
 Infectious Diseases Diagnosis

Who is the host? (what environment?)

Host How is the host defenses like?

What infective agent?

Infective agent

What anti-infective agent?

Site of infection
How best to administer? (route, dose)
Principles of anti-infective agents

Right indication (right patient, right disease, right risk factors)

Right drug
Right route
Right dose
Right duration
 Learning Objectives
aware of the terms bacteriostatic and bactericidal
categorize antibacterial drugs based on their
classification and mechanism of action
familiar with the pharmacokinetics, mechanism
of action, dosage, usage and important adverse
effects of the following;
Penicillin
Cephalosporin
Tetracycline
Macrolide
Aminoglycoside
Mycoplasma pneumoniae are Somas
silent hunters. They lurk undetected
in the worlds forests, phantoms ever
haunting Somas peaceful
communities.
A 35-year old man from the community presents
with fever and cough for 5 days, chest X-ray
shows features of right lower lobe opacity. What
is your preferred choice of antibiotics?

A. Amoxycillin-clavulanate
B. Piperacillin-tazobactam
C. Ceftazidime
D. Imipenem
E. Vancomycin

1
 About the bug
What is most likely?
Where is it?
 A 65-year old man, from nursing home, recent
admission to hospital for UTI discharged well. Now
presents with fever and cough for 5 days, chest X-ray
shows right lower lobe opacity. What is your preferred
choice of antibiotics?

A. Amoxycillin-clavulanate
B. Piperacillin-tazobactam
C. Ceftazidime
D. Imipenem
E. Vancomycin

2
 About the bug
What is most likely?
Where is it?
What antimicrobial pattern?
Community, hospital, nursing home
Previous antibiotic use
Potential resistant organisms (ESBL, MRSA,
MDRAB, etc.)
Antimicrobial susceptibility testing
Qualitative tests (S, I, R)
Quantitative tests (MIC, MBC)

The difference between bacteriostatic vs. bactericidal

A 65 year-old man presents with fever, shock and
with progressive worsening breathlessness (over
past 4 days), chest X-ray showed right lower lobe
opacity. What antibiotics would you choose?

A. Imipenem
B. Imipenem + vancomycin
C. Amoxycillin-clavulanate
D. Piperacillin-tazobactam
E. Ceftazidime + Penicillin + Vancomycin

3
 Empiric antibiotics
Broad spectrum cover to cover likely
organisms
Narrow the spectrum once cultures confirm
Treat initially based on best guess, then change
antibiotics later when more information is
available
These are 3rd Generation warriors from a noble family of apothecaries.
The irony lies in that while perfecting their skills against Gram negative
pestilence (E.Coli, Klebsiella) they have weakened against Gram positive
creatures (Staphyloccus and Streptococcus).
 A 55 year-old man with poorly controlled diabetes
complicated with neuropathy and vasculopathy
presented with infected diabetic foot ulcer growing
MRSA. Sensitive to vancomycin and bactrim. He is
planned for debridement. What is your antibiotics of
choice?

A. Vancomycin
B. Bactrim (oral)
C. Cloxacillin
D. Linezolid
E. Daptomycin

4
 Antibiotics therapy

Pharmacokinetics
Absorption
Distribution
Elimination
Toxicity
Pharmacodynamics
Synergistic effects of drugs
Post-antibiotic effect
 Absorption: BIOAVAILABILITY
IV
rapid and complete, immediate peak
Most often chosen in severewith
Oral antibiotics infections
good
Other routes (IM,bioavailability:
oral)
Fluoroquinolones
Less rapid,Metronidazole
less certain
Doxycycline
Affected by physiological alterations
Bactrim
Peak levels not as high as IV
 Factors affecting bioavailability
Poor circulation associated with hypotension
Altered gastrointestinal absorption due to ileus,
colitis, bowel ischemia, changes in gastric pH
Drug-drug interaction
 (Volume of) Distribution

VD = A/Cp
drug Plasma
concentration

Dynamic process Water vs. lipid soluble

Distribution Obese
Metabolism Fluid overload (cirrhosis,
Elimination heart failure, pregnancy)
 Cannot arrive at target
Circulation to site of infection
Poor vascularity
Nature of infection
Abscess (not penetrated by blood vessels)
Site of infection (privileged sites)
Eye, prostate, CNS
A 22 year-old man with fever and neck-stiffness,
investigation findings (CT Brain and LP) suggest
pneumococcal meningitis, what antibiotics would
you give?

A. iv penicillin G 4MU q4h

B. iv penicillin G 4MU q6h
C. iv ceftriaxone 2g q24h
D. iv ceftriaxone 2g q12h
E. iv vancomycin 50mg/kg/d

5
 Extravascular space

Lipid soluble drugs more easily

move to extravascular space

Protein bound
drugs stay in Infective source
intravascular
space

Capillary
membrane
Increase permeability to cytokine
intravascular mediated inflammation
 Examples
Lipid soluble drugs Water soluble drugs
Chloramphenicol B-lactams
Metronidazole Aminoglycosides
Rifamicin glycopeptides
 Local factors on antibiotics
effectiveness
Aminoglycosides less active in anaerobic
environment (penetration O2 dependent)
Presence of deactivating enzymes (e.g. B-
lactamases)
Slower growing bacteria not as susceptible to
antibiotics that are active against actively
dividing cells
Presence of foreign body (biofilm)
 Elimination
Rate of elimination is expressed in terms of
half-life
>90% of dose is eliminated by 4 half-lives
Redosing-elimination and accumulation of
residual drug => equilibrium/ steady state
(after 4-5 dosing intervals)
Loading dose accelerates this process
 Toxicity
Renal or hepatic impairment
Seizures: imipenem, penicillins,
fluoroquinolones
Exacerbate renal failure: aminoglycosides
Hearing impairment: high levels of
vancomycin or aminoglycosides
A 45 year-old man presented with 2 week history of fever and
features of infective endocarditis. Echocardiograms showed
vegetations in the posterior mitral leaflet. Blood cultures grew
enterococcus faecialis sensitive to penicillin, gentamycin and
vancomycin. What would the antibiotics of choice be?

A. iv penicillin G 6MU q4h

B. iv penicillin G 6MU q4h + iv gentamycin 1mg/kg q8h
C. iv penicillin G 6MU q4h + iv gentamycin 5mg/kg q24h
D. iv vancomycin 15-20mg/kg q12h
E. iv vancomycin 15-20mg/kg q12h + gentamycin

6
 Pharmacodynamics

Synergistic activity
When no single agent is bactericidal,
combination produces a bactericidal effect
Post-antibiotic effect
Allows for regimens that use a single large
daily dose of aminoglycoside in contrast to
traditional shorter dosing interval
 Concentration killing
Higher the aminoglysides above MIC the
greater the kill rate
Aminoglycosides, fluoroquinolones and
metronidazole
Time above MIC
Prolonged exposures above MIC required for
bacterial killing
B-lactams, glycopeptides, macrolides,
clindamycin
Both
clarythromycin
 Summary (bugs)
Bug related
What bug? Where?
Is this a hospital bug?
Whats my best guess?
 Summary (meds)
PK (ADET)
Drug delivery, right dose and duration (time over
MIC vs. peak dose)
Bacterial environment: anaerobic, biofilm, foreign
body
toxicity
PD
Two can be better than one
Post-antibiotic effect
 Antibiotics (role and abuse)
Role Abuse
Respiratory symptoms + indications of dont know what they have
chest infection. antibiotics given to cover
the most likely organisms that can cause
that
... Underlying prosthetic heart valve that just in case they get infection and die
is a risk factor for infective endocarditis
during dental procedure. prophylactic
antibiotics
what is the cause of the fever? Other got fever. Must be infection. Give
causes of fever include underlying antibiotics
malignancy, rheumatological disease,
drug related, etc.
lets deescalate the antibiotics based on just use meropenem, it can cover S.
the culture and sensitivity results. pneumoniae (and everything else)
lets surgically drain the abscess, and antibiotics will kill everything
antibiotics will help prevent
dissemination
END